A 54-year-old man comes to the office due to chronic fatigue, decreased concentration, and depressed mood that began about a year ago. The patient says, "I think it all began last year when my wife and I started to fight more than usual. I was having a hard time concentrating at work and was eventually fired, which caused a lot of financial stress that spilled over into our marriage. Pretty soon, my wife started sleeping in the guest room; she said it was because my snoring was getting worse, but I think she was just sick of me." The patient acknowledges sleeping very poorly and awakening multiple times each night. He struggles to look for a new job because he feels so tired throughout the day. He has a history of hypercholesterolemia and hypertension. He has no known psychiatric history. Medications include hydrochlorothiazide and lovastatin. The patient drinks alcohol socially, although he has been avoiding social gatherings recently despite previously enjoying being around others. He is 175 cm (5 ft 9 in) tall and weighs 118 kg (260 lb); blood pressure is 140/85 mm Hg and pulse is 78/min. Physical examination shows no other abnormalities. Laboratory values are within normal range. Mental status examination shows depressed mood with a full range of affect and no suicidal ideation. Which of the following is the most likely diagnosis in this patient?

Question

A 54-year-old man comes to the office due to chronic fatigue, decreased concentration, and depressed mood that began about a year ago.  The patient says, "I think it all began last year when my wife and I started to fight more than usual.  I was having a hard time concentrating at work and was eventually fired, which caused a lot of financial stress that spilled over into our marriage.  Pretty soon, my wife started sleeping in the guest room; she said it was because my snoring was getting worse, but I think she was just sick of me."  The patient acknowledges sleeping very poorly and awakening multiple times each night.  He struggles to look for a new job because he feels so tired throughout the day.  He has a history of hypercholesterolemia and hypertension.  He has no known psychiatric history.  Medications include hydrochlorothiazide and lovastatin.  The patient drinks alcohol socially, although he has been avoiding social gatherings recently despite previously enjoying being around others.  He is 175 cm (5 ft 9 in) tall and weighs 118 kg (260 lb); blood pressure is 140/85 mm Hg and pulse is 78/min.  Physical examination shows no other abnormalities.  Laboratory values are within normal range.  Mental status examination shows depressed mood with a full range of affect and no suicidal ideation.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's presentation is strongly suggestive of obstructive sleep apnea (OSA). The STOP-Bang questionnaire is used to quantify risk for OSA, and this patient would be scored as high risk based on the presence of snoring, excessive daytime sleepiness, hypertension, BMI >35 kg/m², age >50, and male sex. OSA frequently presents with depressive symptoms such as fatigue, sleep disturbance with multiple awakenings, impaired concentration, irritability, and low mood. A primary depressive disorder (eg, major depressive disorder) should not be diagnosed in this patient because evidence from the history and examination suggests a medical condition (ie, OSA) as the likely cause of his depressive syndrome. STOP-Bang questionnaire ² Clinical diagnosis of OSA is supported by a bed partner's report of snoring, breathing pauses, and nocturnal gasping and is confirmed by polysomnography demonstrating obstructive respiratory events. Appropriate treatment of OSA (eg, positive airway pressure, oral appliances) has been shown to improve associated depressive symptoms. (Choice A) This patient's psychosocial stressors (ie, job loss and resulting financial stress) are a consequence rather than a cause of his OSA-related depressive syndrome. Adjustment disorder is not diagnosed when another disorder better explains symptoms. (Choice C) Major depressive disorder is not diagnosed when symptoms are caused by a medical condition, as in this patient. (Choices D and F) Hydrochlorothiazide and lovastatin are not known to cause depression. This patient's social drinking would not explain his persistent symptoms. (Choice E) A diagnosis of persistent depressive disorder (dysthymia) could be considered, but it would require a duration of 2 years and evidence that symptoms persist despite treatment of sleep apnea. Educational objective: Diagnosis of primary mood disorders (eg, major depressive disorder) requires exclusion of medical and substance-induced causes. Untreated obstructive sleep apnea can present with symptoms that overlap with depression (eg, low mood, fatigue, sleep disturbance, impaired concentration). References: The effect of treating obstructive sleep apnea with positive airway pressure on depression and other subjective symptoms: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26454823) Effect of treatment of obstructive sleep apnea on depressive symptoms: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25423175)

A 54-Year-Old Man Comes to the Office Due to Chronic